00:00:01: In terms of decision-making for an upper GI cancer, which is bleeding with our established therapies or established modalities.

00:00:07: even our established algorithms don't work.

00:00:10: Welcome to the ESGE podcast Indoscopy Unplugged!

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00:00:17: experts

00:00:18: and where we'll discuss

00:00:20: relevant clinical topics...

00:00:21: ...and provide you

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00:00:39: Hello everyone, welcome to episode six of ESGE's podcast Endoscopy Unplugged.

00:00:45: My name is Ayan Grolnik past president of DSG And I am your host.

00:00:49: today's podcast is entitled crisis management one-on-one endoscopic hemostasis for peptic ulcer bleeding and my guest is Dr.. John Morris Consulting gastroenterologist at the Glasgow Royal Infirmary in Glasgow Scotland.

00:01:03: John is a senior author of many original publications and upper GI bleeding, and he's co-author on the ESG Guideline on Peptic Ulcer Bleeding update twenty twenty six where he has served as a task force lead.

00:01:16: that ESGE guideline was published online last month.

00:01:19: so congratulations john.

00:01:21: welcome to the podcast

00:01:22: thank you i am

00:01:23: great to have you here now.

00:01:25: before we start i wanna ask how do u decide to pursue a career in gi endoscopy.

00:01:39: being a physician and analyzing the issues in front of me, but I very much appreciated the opportunity for hands-on treatment.

00:01:46: And i could clearly see the future from minimally invasive treatments on their opportunities to endoscopy make a material difference to quality life.

00:01:54: so it was actually quite an easy choice.

00:01:57: Same For Me Likewise.

00:01:58: But let's get into endoscopic management of Peptic Ulcer Bleeding.

00:02:02: So you have patient John who has having an upper jet bleed form a PeptiC ulcer whether its gastric or duodenal.

00:02:08: And one of my questions is what scopes do you recommend we should be using in that situation?

00:02:15: Is it a diagnostic gastroscope, therapeutics scope...

00:02:18: Well and this has actually evolved over time for me because previously we would have used a dual channel endoscope.

00:02:24: But with the more modern gastroscopes but larger working channels our go to endoscopers at three point eight millimeter working channel.

00:02:33: I think its really important.

00:02:34: these endoscopes got water wash capability built-in So that you can clearly see the pathology.

00:02:40: You're trying to identify.

00:02:41: so these days, it's a therapeutic gastroscope single channel That I prefer.

00:02:47: i'm right there with ya.

00:02:48: we have a single-channel Therapeutic scope.

00:02:50: We also have a double Channel.

00:02:52: When I give talks and I've heard you say The same thing?

00:02:55: I really think in this situation With peptic ulcer bleeding we should not be using A diagnostic size channel Gastroscope.

00:03:02: But because we're just not going to be able use large sized tools, they are just not gonna fit down the working channel of a diagnostic scope.

00:03:09: Yeah and I think it's all about right endoscope.

00:03:11: Agree!

00:03:12: Alright so you there?

00:03:15: You've realized this is peptic ulcer bleeding.

00:03:18: in terms of forest classification who will deliver endoscopic hemostasis too?

00:03:22: Well for me very much adhere with international guidelines.

00:03:27: So its Forests one A One B two A absolutely For me, I think it's very obvious that we should also be treating the forest to be lesions.

00:03:37: And I suspect there is probably a group internationally who are under-treated and perhaps could get treated better.

00:03:42: So you're talking about the adherent clot?

00:03:43: The non-bleeding adherence clot patient?

00:03:45: Correct!

00:03:46: Okay...I'm with ya'.

00:03:48: But the only caveat is if your going treat those adherents in clots then they need ready for things starting to bleed so you can unleash a torrential bleeding.

00:03:59: Capable with your endoscopic skills.

00:04:01: I agree with you, i would treat those types of patients.

00:04:04: but let's talk about active bleeding.

00:04:06: so Let me know what's your go to endoscopic hemostasis therapy if you have a forest one day or force be bleeder.

00:04:14: well this is actually an evolving area for me.

00:04:16: i am as you know but I still adhere to the wisdom of dual and scopic therapy.

00:04:21: there is no rule nor room for monotherapy particularly with simply epinephrine or adrenaline injection.

00:04:27: so i would use adrenaline ejection plus heater over gold probe.

00:04:31: but also endoscopic clips.

00:04:33: There's a lot of decision-making goes into which modality, depending on the lesion and the ease of access to deliver the therapy.

00:04:39: So

00:04:40: when you inject with epinephrine... You're injecting dilute epinephrine?

00:04:45: What is your concentration that you are using?

00:04:47: Yeah so we use one in ten thousand.

00:04:49: I think biggest mistake people make it.

00:04:52: they are far too timid for their volume.

00:04:57: Thirteen to fifteen mils, but actually I could easily see myself using more up to twenty mils.

00:05:03: Twenty five mils.

00:05:04: The important factor here is not to make your access to the bleeding lesion Uh, worse as a result.

00:05:11: Right?

00:05:12: Um so it's about where are you going to inject.

00:05:13: how much Are You Going To Inject and include communication with the team?

00:05:16: So Where are you injecting?

00:05:17: so

00:05:18: I actually would tend to for example if you think About either posterior duodenal wall ulcer or high lesser curve i'll tend to inject downstream.

00:05:26: so in The more distal part of the lesion And i'm injecting around the periphery and hopefully four separate Quadrants and then probably i will also inject into the center of the legion at that point

00:05:39: Also you do.

00:05:41: We have to make it compromise because if we inject and make the visible lesion more difficult to treat, either with a clip or with the probes then perhaps were doing a disservice.

00:05:51: so I think It is a judgment call.

00:05:53: So

00:05:53: um If your gonna use let's say through-the-scope Clip as your combination therapy are you doing that in?

00:06:00: How did you choose if you're going to use actually uh Through The Scope Clp Or even an over the scope clip As That Second hemostasis there.

00:06:09: So this is where the evolution has come.

00:06:10: I am and you know, I think all of us are now very much aware Of the significant impact that over-the-scope clipping The evidence does support these of ease in first line therapy.

00:06:20: But with all endoscopic therapies, you have to adjust your therapeutic armamentarium according to the anatomical position and also the technical skills required.

00:06:31: So for example if you have a D-one d two posterior ulcer maybe not the best for OTSC clip.

00:06:36: If I'm going to use an over the cap mounted clip i may actually tend to use less injection therapy because I feel like im gonna get really good tissue acquisition.

00:06:47: So in that situation, I use a minimal amount of adrenaline injection to facilitate the sucking of the pathology into the cap.

00:06:57: But i don't want to obscure the pathogy and make my life more difficult... ...I may actually go for a cat-mounted clip or monotherapy

00:07:04: Even if it's actively bleeding.

00:07:06: you're not going try slow down even with some dilute epi?

00:07:09: Well

00:07:10: thats' my point!

00:07:10: A small amount.

00:07:12: just give yourself clear view where the bleeding lesion is.

00:07:15: But actually, you know these are very effective therapies now.

00:07:18: so if we can control this on a sort of single modality approach I'm happy with that.

00:07:25: Yeah

00:07:25: and i especially like them in the larger fibrotic ulcers where often times through the scope clips they're just not strong enough to take care of it.

00:07:38: What are your thoughts about that?

00:07:39: Yeah,

00:07:39: absolutely and you know the critical thing was when we evaluate the evidence... We need to appreciate some studies that were done on Katmander clips actually selected the lesion for use in Katmanda clip-ons.

00:07:50: so when we interpret literature we have to be a little cautious about firstly primary hemostatic success but secondly long term hemostasis.

00:07:59: I think this is really attractive technology particularly as we all know our standard endoscopic therapy.

00:08:05: even at best hands will fill control bidding up to ten, maybe fifteen percent of the time depending on the lesion that we are identifying.

00:08:12: Is there

00:08:12: a learning curve with cat-mounted clips in your opinion?

00:08:15: Well

00:08:16: I think there's a lot of mistake around the use of the cat-mounted clips and i would say to people listening about actually if you can use a variceo band legator then actually technology is remarkably similar...I do think yeah ...that perhaps at an era where specific either training courses for endoscopic hemostasis or some demonstrable competency it should be wired before using the clips.

00:08:39: I'm an advocate that i think we should absolutely have these as part of our armamentarium or in our toolbox and our endoscopy suites for sure today to use in GI bleeding.

00:08:49: let me ask you something else because, I get asked this question non-bleeding visible vessel are a forest to a lesion?

00:08:55: do preinject around that area with dilute epinephrine?

00:08:59: Or just some type of omonotherapy?

00:09:02: Well

00:09:02: im aware of guidelines on this.

00:09:05: I have experience where actually you can make it more difficult to deliver the therapy.

00:09:10: For me, if you're going to deliver mechanical therapy It's much less necessary to inject adrenaline.

00:09:15: but by habit i always usually injected some adrenaline as an adjunct and remember that we need to understand the pathology of peptic ulcers in an end artery which is coming, you know in the sense like a jewellery which comes straight through the mucosa.

00:09:33: Often these are lesions that run parallel to the surface.

00:09:39: Let me go back because we talked about using contact thermal therapies.

00:09:44: if We're going to use a bipolar probe.

00:09:48: What are the settings?

00:09:50: How do you approach utilizing?

00:09:51: because I sometimes find with younger generation, they actually not even that familiar contact thermal probes.

00:09:57: but some of us older people like UNI were trained on those types of modalities.

00:10:04: Our go-to when we were sort of beginning this journey in endoscopic hemostasis was the heater probe.

00:10:11: Unfortunately, we no longer have that available but we're using injection gold probe.

00:10:15: The beauty here is as with highlighted anatomy can be critical to success of endoscopy therapy and you get a degree of tangential application pressure that will calculate the vessel.

00:10:27: really important point you make here about the amount of power.

00:10:30: Firstly, we modify the power settings in the duodenum compared to this stomach.

00:10:35: usually my experience is that gastric ulcers have a more chronic and injuring base.

00:10:39: so I'm probably using the region of thirty watts per hour whereas then the duodinum twenty-twenty five.

00:10:46: so i've been using less heat than the duody nymph.

00:10:50: it's very thin gold um... And You see that at laparotomies uh.. That actually can Very often See uh, where you've been delivering therapy through the wall of the duodenum.

00:11:01: So you have to be careful when applying heat in that situation

00:11:05: and When you're trying to apply a co-aptive coagulation And your pushing down right?

00:11:09: You know using here these watts how long are you holding the probe there in place?

00:11:13: I want to see a footprint.

00:11:15: it's really important so It's probably going to be two or three seconds with the gold probe.

00:11:21: Actually Of course with the heater probe There was a natural duration of them up.

00:11:25: when you hit the foot switch There was a natural human, and then it stopped.

00:11:28: That's right!

00:11:29: It would automatically turn off... Yeah but

00:11:30: I mean i have- And again you know bleeding peptic ulcer.

00:11:33: if we discuss with surgeons they'll say look there is very little between the bleeding pectin ulcer or an bleeding peptin Ulcer with a perforation.

00:11:42: You do need to be careful But again you need apply coaptive coagulation.

00:11:46: So let me change gears a bit too.

00:11:48: another type of hemostasis modality that has come along.

00:11:52: So what about topical agents or powders, or gels?

00:11:55: Where in your opinion do they fit today in a peptic ulcer bleeding?

00:12:00: and what is?

00:12:01: the literature tells us.

00:12:01: What's the evidence?

00:12:02: so I think we're at quite an important point In the journey in use of hemostatic pyrolysis.

00:12:08: You know We were very fortunate here in Glasgow to be one amongst the first world to have used Topical hemostats.

00:12:14: it makes sense because firstly They are very attractive in terms of their ease of abuse They're fairly simple and the ability to deliver has improved considerably.

00:12:24: So we absolutely supported the use of hemostatic powders in two contexts, one as a rescue therapy on secondly particular patients who've got bleeding upper GI cancers because you know I In terms of decision making for an upper GI cancer which is bleeding can be real problem are established therapies or establish modalities.

00:12:43: even our established algorithms don't work you can make things a lot worse.

00:12:47: So we saw some spectacular success with this and as you know, the RCT has shown superiority of hemostatic powders in cancer bleeding.

00:12:54: I think that's for me is an argument but it was one that should be first line when i think its really important to appreciate part of the literature that we've looked at as part of their twenty-twenty six guideline update.

00:13:05: there s just increasing sense.

00:13:07: actually if we look at generalizability and the skill set that's required to deliver those techniques, perhaps there may be a role for these hemostatic powders as first-line therapy.

00:13:18: Now that makes me nervous because intuitively if we have a forest IA one would be lesion then are we seriously thinking they will have enough hemostatic impact to actually stop that vessel from bleeding or indeed re-bleeding?

00:13:34: But when you look at the meta analysis They stuck it well because of these views and the technical challenges that every day we face.

00:13:45: However, I would urge those people listening to dig deeper into literature... ...because the literature clearly highlights a lot of this meta-analysis.

00:13:51: do not separate peptic ulcer bleed from cancer bleed It's general statement but should be your first line therapy.

00:13:57: So intuitive you think change guideline?

00:13:59: But i don't think were there yet We have qualified acceptance that paradigm may shift.

00:14:06: There may be lesions where topical powder first line is best, and there maybe endoscopus were actually been the patient's best interest for topical therapy.

00:14:16: I think in twenty-twenty six The jury still remains on my view out although i think we are at a point Where We should Be moving this these further forwarding algorithm.

00:14:26: so very neat paper recently Actually And let me just highlight This which was the addition of a hemostatic Powder after successful endoscopic therapy.

00:14:37: We do recognise that whilst we talk about dual endoscopy therapy, sometimes actually may extend to triple-therapy and for me the recent paper which suggested atop of hemostat post successful endoscopic therapy might have additional benefits was very attractive.

00:14:52: so it's just a question looking clearly what modality that was used as the primary hemostatic agent, and that's where it just fell down a little bit for me because actually they weren't using dual therapy.

00:15:03: They were using monotherapy with heat.

00:15:05: so although they had hemostasis I'm not sure we can generalize that.

00:15:08: The jury is out but i think the hemostatic patterns are moving up their algorithm...

00:15:11: Well if truth were to be told and to be honest with you ,I've done this myself on occasion .

00:15:17: I have thrown powder after what I thought was adequate haemostasis.

00:15:25: I think sometimes you sleep better at night, if you've added something on there.

00:15:29: And that goes more than we

00:15:32: think."

00:15:32: It's a

00:15:55: good point, but let say what are you doing things or just not.

00:15:58: You're not able to treat something endoscopically?

00:16:01: What do you at that point?

00:16:02: who would pick up the phone and call

00:16:04: next?".

00:16:05: This

00:16:05: is really important thing for me.

00:16:07: it's about this scenario.

00:16:08: Are we under control as patient?

00:16:10: he meant him and the man was stable.

00:16:12: so if I have patient who's had massive GI bleeding that I've struggled to get endoscopic therapy, often a priori beforehand before I carry out my endoscopy.

00:16:21: I'll speak with my surgical team and say look i'm gonna try to stop this bleeding.

00:16:25: but i'm pretty clear given for example extreme high blachford the ongoing resuscitation need... This is going to be a high-risk lesion!

00:16:33: And so can we make sure It all comes to the point where we cannot control bleeding.

00:16:38: and in my career I have seen people recording immediate surgery.

00:16:41: To save their life then, than the team is already alerted.

00:16:44: We make a lot of taste so of arterial embolization which has very effective therapy.

00:16:51: but there's number factors that guidelines i think don't take into account such as availability out-of-hours of radiologist skilled enough material embolization, how close are you with that patient to an IR suite?

00:17:05: Because if we get no point where the patients clinically unstable it becomes actually unsafe to put them into a radiology suite.

00:17:12: It's safer for them to be in theater and to get stabilization.

00:17:15: remember they're bleeding does stop.

00:17:17: And so as long as we can get control of resuscitation from colleagues intensive care there is nothing lost by starting on PPI because bleeding does come and go.

00:17:31: And it's not inconceivable that you would say, I can't deal with this at the moment?

00:17:36: I'm going to give this patient a PBI but I feel if i could go back in twelve hours or twenty four hours.

00:17:42: as long is patients stable then than our second attempt endoscopy.

00:17:46: Do

00:17:46: do have twenty-four hour day IR coverage?

00:17:49: we do... We have actually one of our neighbouring hospitals.

00:17:55: IR team will come to our hospital.

00:17:57: Unfortunately, my experience with that has been often our interventional radiologists.

00:18:02: firstly they would ask for a CT angio first line.

00:18:06: if you have critical illness situation then it's not in my opinion being helpful.

00:18:12: but secondly...

00:18:14: Just because your worried about them doing bad things during the CT?

00:18:17: Because its delaying therapy.

00:18:21: The second thing is we need to be really clear, unless you have a very experienced interventional radiologist who's used to doing this.

00:18:28: Actually selectively targeting the vessel that we wish them target can be very challenging.

00:18:34: for example in the duodenum remember?

00:18:36: In the stomach there is rich anastomotic network of arteries coming on lesser curve and greater curves.

00:18:43: so it has been highlighted to me by Collison IR That actually simply asking them to embolize in a very selective way Can Be Quite Challenging.

00:18:51: When a patient, let's say that endoscopic therapy is just not working and you're going to pick up the phone Oh, the endoscopic site from where it's bleeding.

00:19:02: Are you placing a clip there to help guide the radiologist?

00:19:06: Give them a

00:19:06: roadmap?".

00:19:07: Yeah

00:19:07: absolutely because... The other thing about bleeding for many lesions particularly at Pepticale Services is intermittent and so the ease with which a radiologist can actually identify the bleeding site depends on actually the sight-bleeding.

00:19:20: So it could be really quite challenging but without.

00:19:23: she had quite a number of experiences where IR colleagues did try to embolize, couldn't find the bleeding spot or thought they'd embolized it in their spot and then the patient rebleeds.

00:19:30: So we never talk about rebuilding post-IR particularly.

00:19:33: I agree with you.

00:19:34: We had a case very similar that just a few weeks ago And patient had rebleed and went back in endoscopically and stopped at your hospital.

00:19:42: Do you have twenty four seven emergency endoscopy?

00:19:46: Services available for bleeders.

00:19:48: Yes, we do and I think that's really should be standard.

00:19:52: In my opinion.

00:19:52: all over the world guidelines have been talking about that now For at least ten to fifteen years.

00:19:58: That needs to be a service that hospitals provide.

00:20:01: Yeah Actually i'm actually.

00:20:02: i think you need someone who is skilled To deliver that therapy.

00:20:05: he was doing it on a regular basis?

00:20:14: who should be on an on-call road such that they remain skilled in delivery of these endoscopic therapies.

00:20:19: If you have thirty people, if you think about it, our hospital will admit four hundred patients with upper GI bleeding... About twenty five percent of those would require intervention ...if we have ten gastroenterologists on call to deliver therapy then on average per annum there may a really small number of episodes where the endoscope is delivered by individual person.

00:20:40: So the risk of de-skilling is there, but actually using new technology also becomes challenging because how do they become familiar with that?

00:20:47: My view and I think you've heard me saying this before—I think hospitals need to decide their optimum number —but it shouldn't be the entire GI or surgical

00:20:55: team.".

00:20:55: And as we know something similar in Paris where an endoscopist and a fellow travel around in a number of hospitals to deliver therapy... That's brilliant model!

00:21:06: In a taxi they travel

00:21:08: That's right.

00:21:09: Maybe he is cheaper to go by tax in Paris than it isn't.

00:21:12: Well,

00:21:13: we had a hemostasis team at UCLA when I was there and they've had...I don't know if they still do?

00:21:17: They used have a hemostatis or bleeding team at Mayo Clinic in Rochester but that's not the common.

00:21:24: let me tell you And i agree with what your saying There are lot of attendings who take emergency call Who dont feel comfortable treating GI bleeding just because they don't see enough of it.

00:21:34: Yeah,

00:21:34: we identified this in the UK some time ago and we started a dedicated one-day GI bleeding course.

00:21:42: that was for trainees and established consultants.

00:21:46: And ironically... The biggest number people who subscribe to us were established at consultants or attendings.

00:21:53: Because if you have the insight to realize there are new technologies That you can deliver better care then you probably make a better person be on a GI bleeding rotor.

00:22:01: Just tell everybody, all of our listeners how do you give your PPI post therapy and for how long?

00:22:05: Well

00:22:06: like you I was almost trained on the Hong Kong so-called Hong Kong protocol which is IV PPI Post procedure.

00:22:13: Anyone who done endoscopic therapy.

00:22:16: The real issue with that from me has been the fact in the current healthcare environment we're in That it confines a patient to hospital.

00:22:24: So i think more recently We've switched to high dose oral PPI twice daily.

00:22:29: I'm pretty convinced of the equivalence of those, and particularly for patients where you're very happy there's a low risk of reblead than high dose OPPI which can then be taken on discharge.

00:22:41: But do put them in like twenty four hours afterwards?

00:22:43: You keep him in house for twenty-four hours.

00:22:45: that transition

00:22:46: though?

00:22:46: Yeah exactly so if we've intervened endoscopy thing something is really important.

00:22:51: point um... Is when do you refeed someone?

00:22:54: When Can You Allow One To Have A Meal?

00:22:56: And my view.

00:22:56: Um, is it's really simple that if you have convinced yourself That you've delivered endoscopic therapy and the patient can eat and go back to normal activities after twenty four hours But there was any doubt uh where?

00:23:08: You're not.

00:23:08: You know your unsettled patients perhaps been stable but they you Know those high-risk features then than perhaps keeping that patient fasted a little longer.

00:23:16: It's not a bad idea.

00:23:17: in case you have to do second endoscopy.

00:23:18: Yeah We usually don't keep patients for seventy two hours.

00:23:22: we either will put them initially for twenty four Hours up at.

00:23:24: Then you could also give them sort of BID dosing of IV if you want to or put them on the high dose aurels afterwards and send them out.

00:23:34: If it's possible, they don't have any other severe comorbidities that would keep them in the hospital at that point?

00:23:40: I think that's a trend we'll see more off.

00:23:41: The reality is pretty reassuring.

00:23:47: Yeah,

00:23:47: absolutely.

00:23:48: last less the issue I wanted to talk you about.

00:23:51: so Peptic ulcer bleed.

00:23:52: tell me how you approach testing and treating H pylori.

00:23:56: are you taking a biopsy during that endoscopy?

00:23:59: what do you doing?

00:23:59: Are you doing rapid urease testing or your sending an actual biopsey for histology?

00:24:04: because i get that question all time.

00:24:06: really glad you mentioned this one because it is something that somewhat frustrates.

00:24:11: We understand that if we have blood in the stomach, it may affect you know accuracy of urea test.

00:24:18: So my view is very pragmatic.

00:24:19: absolutely take a biopsy for rapid urease testing because If its positive then patient will receive helicobacter eradication and can have an uro breath test at interval post discharge to ensure they've had helicobacter eradication

00:24:35: Which is really important to document if they've had a complicated ulcer.

00:24:39: Correct,

00:24:39: however... If you take an urea test and it's negative not patient should be booked for early urease tests To check that there are actually positives.

00:24:48: So

00:24:49: here what I do or my department does because this was asked them.

00:24:54: so i do the rapid ureases but at same time I take additional couple of bites and put it in a histology bottle.

00:25:03: And if the rapid urease test is negative, I send it for histology to see because i'm not always convinced that the patients will come back and do the breath testing or stool testing

00:25:13: afterwards.".

00:25:19: Bled from a peptic ulcer, and I really want to make sure if they're positive.

00:25:23: They are going get treated.

00:25:24: that's what we do.

00:25:25: And the other thing is If The Rapid Urase Test Is Positive We Actually Recommend Them Starting Antibiotic Therapy Especially If They Are Going To Stay In The Hospital For A Few Days.

00:25:33: We Start Them Already.

00:25:34: On Antibioid Yeah

00:25:35: What You Describing Is A Very Pragmatic Approach.

00:25:39: Taking into Count Your Population Adherence We Understand That Your Patients May Not Come Variet Patient Follow Up afterwards.

00:25:47: That's a kind of unique solution, I haven't used that

00:25:49: before.".

00:25:49: Yeah and if their rapiduria test is positive...I throw away the histology bottle- I waste a bottle.

00:25:55: but i guess that's the price we prefer for that pragmatic approach.

00:26:00: All right well listen John!

00:26:02: I think we've come to the end of our podcast here.

00:26:05: I want to thank you again very much for being here having an international expert like you on this podcast.

00:26:10: talking about hemostasis I don't know if you're a big sports fan.

00:26:17: I follow my Minnesota Sports teams, the Twins and the Minnesota Vikings in football...I just wanted to ask it so our listeners can get more of an background on who John Morris is.

00:26:28: Do you play sports or do have favorite sports team?

00:26:31: What are your guys doing up there in Glasgow?

00:26:34: Yeah!

00:26:35: I'm pretty fanatical about the outdoors irons.

00:26:38: for me its skiing & windsurfing travel around the world doing these and it's fantastic to be out there in nature.

00:26:45: And I know you're a golfer, right?

00:26:47: We both are golfers so hopefully one day we'll get our game into the future.

00:26:52: But listen thank you again for being here!

00:26:54: It has been wonderful to have ya' and have a great rest of your days.

00:26:57: Thanks

00:26:57: Arne.

00:26:58: Thankyou for listening this episode of Endoscopy Unplugged.

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